The role of digital literacy in achieving health equity in the third millennium society: A literature review

Healthcare in the third millennium is largely delivered through systems involving the use of the technological devices and services, foremost among them telemedicine. For the adequate delivery of digital medicine services, however, it is necessary for users to be digitally literate, that is, able to consciously make use of technology. In order to understand how relevant digital literacy is in determining the effectiveness of e-Health services, we performed a traditional literature review on 3 major databases by combining the terms “Digital Literacy” and “Computer Literacy” with the terms “Telemedicine” and “Telehealth”. Starting from an initial library of 1,077 papers, we selected 38 articles. At the outcome of the search, we found that digital literacy is a pivotal element in conditioning the effectiveness of telemedicine and digital medicine services in general, however, with some limitations.

to the emergence of the concept of "digital health", defined by the WHO as "a broad umbrella term encompassing eHealth (which includes mHealth), as well as emerging areas, such as the use of advanced computing sciences in "big data", genomics and artificial intelligence" (5).
In 2006, Norman and Skinner (6) proposed a conceptual model encompassing six different literacy domains needed to process information from technological sources: traditional literacy, health literacy, information literacy, scientific literacy, media literacy and computer literacy. According to the authors' view, health literacy consists of the ability to perform basic reading and numeracy tasks necessary to function in the health care environment, so individuals with adequate health literacy are able to read, understand and act on health information. In fact, the term "health literacy" had been already defined in 2000 as "the degree to which individuals can obtain, process, understand, and communicate about health-related information needed to make informed health decisions" (7). Here, then, is where digital literacy applied to medicine represents what can be called "e-Health literacy" (electronic health literacy), which can be measured and quantified through scales, such as that devised by Norman and Skinner themselves (eHEALS: e-HEAlth Literacy Scale), the best known and most widely used (8). E-Health literacy is one of the key tools to counter the so-called "digital divide", which today translates not simply into the inability of some citizens to access information, but into the preclusion of access to actual health services. It is therefore necessary to understand how today, in the third millennium, digital literacy is much more than a simple technological know-how, but represents a real tool at the service of citizenship, enabling individuals to have equal access to numerous categories of services, including health services.
Precisely because of its growing impact in terms of access to health services, in recent years digital literacy has been universally recognized as falling squarely within the SDOH (Social Determinants of Health), that are non-strictly medical elements that influence a wide range of health outcomes and risks, as well as functioning and quality of life. A major driving force behind the amplification of the primary role played by technology in the delivery of health care services was undoubtedly the COVID-19 pandemic, which by imposing a restriction on interhuman contact forced the adoption of health care measures that could be delivered remotely, by means of technological tools (9). And indeed, it is sufficient to think about the SARS-CoV-2 pandemic to realize how preeminent the role of e-Health literacy is in modern healthcare. Booking an anti-COVID vaccine or swab, accessing the service's website from which to download the test result, booking a blood test to determine the level of antiviral antibodies, accessing the Ministry of Health's website to download the vaccine certificate, interacting via e-mail with the primary care physician: these are all tasks that many of us take for granted, but they require a certain level of digital literacy to accomplish properly.
It is abundantly clear that the problem predominantly affects certain categories of people (the elderly, people with a low cultural level, people living in rural areas, where the access to technology is limited), but one of the cornerstones of an evolved society is equity in healthcare provision, and today, in the third millennium, it seems really difficult to think that this goal can be pursued apart from a serious and structured digital literacy policy.
Since health is a basic human right, the delivery of health services must be done equitably, that is, by ensuring that all individuals could reach their full potential for health and wellbeing. The digital divide brought about by the increasingly pervasive diffusion of technology in health care necessitates the implementation of increasingly efficient education programs in the use of new digital tools, as it has become clear that education is a primary tool for ensuring health equity, no less important than scientific progress (10, 11).

. Aims and objectives
Implementing the quality of the technologies underlying telemedicine services and e-Health services in general without promoting at the same pace the knowledge of the use of IT and digital tools is clearly a strategy destined to fail. According to Watts' claim, in fact, "any healthcare development that doesn't rapidly become available to all individuals has the unintended consequence of fuelling health inequality" (12).
This paper aims to define, through a review of the literature of the past 10 years, the extent of the impact of digital literacy on access to telemedicine services. In other words, we sought to understand whether and to what extent high or low levels of digital literacy are involved in determining the extent to which telemedicine services are used.
. Materials and methods

. . Searching strategy
The research was carried out on the scientific literature between January 2011 and October 2022 in the online databases of PubMed, Scopus, and Web of Science (WoS). The search was performed entering the following base string: ("Digital Literacy" OR "Computer Literacy") AND ("Telemedicine" OR "Telehealth"), limiting the results to English-language articles published in the above time frame. The basic string was, of course, modified according to the individual peculiarities of the various databases on which the search was carried out. We voluntarily omitted to include the databases for the gray literature search to avoid contaminating the review with papers with uncertified scientific validity.
We performed a preliminary skimming independently. Each author read the abstracts of the articles and identified those they considered useful for the review. At the end of the preliminary evaluation phase, the authors discussed the selected articles, debating the suitability of the individual papers. At the end of the selection procedure, the authors read all the articles in order to collect the data for the review.

. . Selection criteria
The research initially provided 1,077 results. Specifically, 223 papers were found in PubMed, 682 in Scopus, and 172 in Web of Science. The types of study objects of interest were original researches, review articles, and perspective papers. We made an .
/fpubh. . initial pre-selection by removing duplicate papers (n = 453) and articles for which the full text was not available (n = 7). We then read the titles and abstracts of the remaining 617 articles in order to identify papers suitable for reading the full text. A total of 94 articles were discarded just by reading the titles, which were clearly not in line with the purpose of the review. After reading the abstracts of the remaining 523 papers, we excluded an additional 293 papers: 107 because they illustrated particular telemedicine services without a clear discussion of the link to digital literacy, 112 because they delved into the topic of digital literacy without particular reference to its impact on access of telemedicine services, and an additional 74 because, although they dealt with the impact of digital literacy on access to telemedicine, they did not provide useful insights to answer the review questions. With regard to the 112 papers excluded because they lack clear references to telemedicine, we would like to point out how we nevertheless decided not to exclude some of the papers focused almost exclusively on digital literacy without direct reference to telemedicine because they related to older age groups, thus of particular interest in answering the review questions.
We then proceeded to read the full text of the remaining 230 papers, of which we decided to include in the review the 37 that we considered most valid and scientifically accurate. Figure 1 shows the article selection process.
. . Quality evaluation SANRA (Scale for the Assessment of Narrative Review Articles) (13) was employed for a quality check of the selected studies. SANRA includes 6 items: justification of the article's importance for the readership, statement of concrete/specific aims or formulation of questions, description of the literature search, referencing, scientific reasoning, and appropriate presentation of the data. A score from 0 to 2 is given for each item. The overall quality was determined as poor (score 0-6), moderate (7,8,10), or excellent (11-13). A total of 24 papers were found to be of moderate quality and 13 of excellent quality.

. . Summary of article pool
The search identified 37 articles suitable for inclusion in this review. The 37 papers were published between 2013 and 2022. Specifically, 1 article was published in 2013, 1 in 2016, 4 in 2018, 3 in 2019, 1 in 2020, 11 in 2021, and 16 in 2022. A total of 14 papers are literature reviews or papers in which the authors express their views on the topic (classic literature reviews, scoping reviews, systematic reviews, perspective papers), and 23 are papers in which actual research was conducted (mainly retrospective and survey . /fpubh. . studies). Given the large number of articles included in the review and the objective difficulty in discursively describing the results of all 37 papers, we briefly illustrated the main characteristics of the selected papers within Table 1. The articles were listed in order of year of publication.

. Discussion
The insights provided by the analysis of the reviewed articles are numerous. A first fundamental point seems to be the importance that is universally recognized to digital literacy as the key to ensuring an equitable distribution of health services in the society of the third millennium, permeated by digitization and technologization (16, 20, 27-29, 33, 35, 37, 47, 50). In order for it to succeed, it is essential that the promotion of digital literacy should not be a temporary and circumscribed measure, but on the contrary should take on a structural character and be explored at all levels of the organization of society (21). This is important, for example, when considering the fact that those who due to economic or logistical difficulties (homebound) have limited access to technological resources (14). A digital literacy project aimed at these segments of the population cannot be fruitful unless there is a concomitant effort to support them economically and socially. Also consider the linguistic aspect (45). It is perfectly useless to digitally literate an individual who then, due to lack of understanding of the language, is unable to use the electronic tools he or she has become capable of using.
Intimately associated with this concept is the principle that ensuring equity of access to digital health through the enhancement and development of digital literacy must be a priority felt by multiple stakeholders: consumers (patient and carers), consumer advocacy groups, health service staff (clinicians, nurses, pharmacists), health services (providers), policy-makers/funders, researchers, and industries (44). This is because telemedicine and medical care provided through digital tools in general is now officially and definitively a concrete and tangible reality, so much so that it is universally recognized as a social determinant of health (SDOH) (30,43). A very interesting idea would be to provide for the introduction of specific teachings on digital literacy within school curricula.
It is very important to note, however, that like any ambitious project, that of adapting digital literacy to the levels of technology that characterize our society today must come to terms with realism. This means that providing for an extension and capillarization of digital skills would risk further exacerbating technological evolution, thus risking leading to a widening of the "digital divide" secondary to the gap that could arise from the speed of growth of digital skills (fast) and the speed of growth of technology (very fast). In other words, there would be a risk of favoring technology that evolves too fast compared to how fast digital skills evolve (23).
It is therefore essential to pursue the goal of supporting increasing digital literacy in a prudent and reasoned manner, also in view of the fact that e-Health services are often, paradoxically, particularly effective in low digitally literate individuals (15). This paradoxical effect is confirmed by the fact that health kiosks represent the perfect paradigm of the digital medicine tool suitable for the person with low digital literacy (36). The reason is simple: although they are highly technological and complex tools, they have a highly intuitive interface for use of which no special computer skills are required. Therefore, some might argue that it would be wrong to concentrate forces in implementing digital literacy of the population, a strategy that would exclude categories of people who are objectively difficult to literate, and that it would be wiser, on the contrary, to try to simplify e-Health technological tools as much as possible, so that their use can be made within the reach of everyone, even those who are not familiar with technological means. Arguably, increasing the digital skills of the general population and developing e-Health technologies with the highest benefit-to-complexity ratio are operational strategies that must be pursued together. In any case, it should be considered how it is objectively inadvisable to take the simplification of e-Health benefits to extreme limits, since simplifying a technological measure often also means preventing it from unfolding its full potential.
Another interesting food for thought that emerged from the review is how to identify individuals who may benefit from digital literacy programs. Despite the fact that very often the category of people unable to independently use digital tools in the service of health coincides with the elderly population, this correspondence is not always true, depending, as the review clearly demonstrated, on numerous other factors. Even the parameter of socioeconomic status is not accurate in defining who is reliably digitally competent and who is not. In fact, not always those with high incomes (and therefore likely to have access to high-level technological tools) possess a sufficient degree of digital literacy to make beneficial use of e-Health services (42). It is therefore essential to develop screening tools that can accurately identify the population groups in need of digital literacy interventions (24, 41). These tools already exist, but, as the literature consulted shows, they need to be considerably implemented. As for developing countries, it should be pointed out that they rely heavily on ICT (Information Communication Technology) tools for their economic survival, competition and progress, which is why it is even more important for digital literacy to be implemented in these areas (51).
It is also interesting to note that, based on the review conducted, it can be concluded that underlying the need to ensure uniform digital literacy should not only be the desire to ensure "equitable" healthcare, but also to prevent the development of "unfair" healthcare. Indeed, those who are poorly digitally literate not only have fewer options in terms of access to care, but are also more vulnerable to the negative and detrimental effects that can result from finding unreliable online information or the product of fraudulent scientific research (49). From this we can see that digital literacy programs are much more than teaching how to become familiar with the technological tools. In fact, making people digitally literate is primarily about teaching them to become aware of the scope and limitations of technological tools in the service of digital health. Clearly, the likelihood of success of this purpose depends largely on the cultural background and knowledge base of individuals (26), but it should not be assumed that individuals with high levels of education are always able to discern what is scientifically valid and what is not, especially if the information   Investigating the role of social support for the use of telemedicine services among the elderly during the COVID-19 pandemic 9 One of the key tools to ensure full access to telehealth services is digital literacy support, which must also be pursued through social support El Benny et al.  Understanding the causes and impact of the digital divide, who is responsible for it, and potential solutions 11 It is crucial that we invest in the implementation of digital literacy as a social determinant of health (SDOH), but on the other hand, given that a good portion of individuals will never cross the digital divide, it is also necessary to ensure low-tech methods of health care delivery  is learned through a technological tool with which they are not familiar. In summary, then, we can conclude how digital literacy is an essential element in the development of equitable digital medicine. However, this is a complex road ahead, given the complexity of the underlying socioeconomic and cultural scenarios, the critical issues in identifying the target population, and the need for a multidisciplinary and multiple stakeholder approach.

. Conclusion
As a final consideration, we can note how it is not only important to implement digital education programs that can bridge as much of the "digital divide" as possible, but how it is equally important to plan for evaluation studies of the effectiveness of such programs in the immediate future.

Data availability statement
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.